Tennis Elbow (Lateral Epicondylitis)

Right Arm Posterior view.

Tendons are white, fibrous bands that attach our muscles firmly to bone.Pain arising from repetitive injury to the tendons that connect the forearm muscles to the lateral epicondyle (outside) of the elbow is called “lateral epicondylitis”.

Lateral epicondylitis, or “Tennis Elbow”, commonly effects individuals who perform manual work; such as painting, construction or landscaping. Only 20% of those affected actually play racquet sports. Lateral epicondylits can result in significant pain and limitation.

Anatomy

Lateral Epicondylitis

This occurs over many years as the result of repetitive tendon injury. The act of griping tools or turning a screw driver, or participation in racquet sports that involve powerful wrist extension or rotation produce recurrent tendon injury. In time accumulation of these microscopic injuries result in elbow pain and limitation.

Predisposing Factors

As we age, degenerative changes occur throughout our muscles, tendons and joints. Tendons suffer microscopic disruption, resulting in decreased fiber strength. Once injured, the weakened tendon is more easily re-injured. The combination of the normal aging process coupled with the repetitive demands of work or sport, can result in “tennis elbow”.

Pathology

Within the lateral tendons of the elbow repeated cycles of microscopic injury, healing and re-injury produce accumulation of grayish gelatinous repair tissue called angiofibroblastic tendinosis. As more and more normal tendon is replaced by weakened reparative tissue, the tendon loses its firm attachment to the underlying bone, and can no longer function without pain.

Symptoms

The symptoms of lateral epicondylitis include elbow tenderness, stiffness, weakness and pain. The pain frequently radiates downwards into the upper forearm. Symptoms can be severe and are aggravated by wrist extension, wrist twisting, and power grasp. When changes within the tendon become advanced, pain becomes continuous.

Diagnosis

The diagnosis of lateral epicondylitis is made through physical examination. X-rays may be helpful to rule out other causes of elbow pain. MRI’s have little if any use in the diagnosis of this painful condition.
Prognosis
Eighty-five percent of patients with lateral epicondylitis can be successfully treated without surgery. Symptoms, however, may recur from time to time before finally and permanently disappearing.

Treatment

Counterforce Brace

A forearm strap or “counterforce brace” can help protect the injured tendon. By squeezing the forearm below the elbow, the strap restricts complete muscle contraction, which in turn, decreases the stress placed on the painful tendon.

Exercise

Increasing the strength and flexibility of the surrounding arm muscles promotes increased blood flow to the injured tendon and encourages more healthy healing. Exercises that strengthen and stretch the forearm muscles are explained on the tennis elbow exercise page.

Medication

Anti-inflammatory medication, or cortisone injections may be helpful in decreasing inflammation and pain. In severe cases, two cortisone injections may be necessary during the course of treatment. Once pain and stiffness are controlled the patient may begin their exercise program.

Surgery

If all else fails, surgery is available to treat tennis elbow. Through a small incision (one and a half to two inches) the tendon sheath is split. The underlying gray, gelatinous angio-fibroblastic tissue is readily visible and easily removed. The underlying bone is roughened providing a fresh healthy bed for tendon reattachment and healing. The split in the tendon is then sutured together and skin is closed.
The wrist is placed in a splint for three weeks before beginning therapy. In general patient may return to heavy work and strenuous exercise approximately three months following repair.
Results of surgery are good. Eighty-five percent of patients recover completely and return to all previous activities, including forceful physical work or racquet sports. In the remaining cases, 10% of patients report significant improvement but have some residual pain with heavy work or tennis. The last five percent of patients, for reasons not fully understood, fail to significantly improve.

A conservative program of bracing anti-inflammatory medication, judicial cortisone injection and progressive strengthening will provide the best opportunity for complete recovery from lateral epicondylitis without surgery.

This information is provided by Orthopedic Spine and Sport Medicine Center as basic information about a specific orthopedic topic. It is not intended as a personal reply to your specific questions or concerns. It is hoped that the contents of this instruction will help you understand the nature of your orthopedic problem and the possibilities of treatment. The final decision regarding treatment, however, must take into account the possibilities of outcomes and complications and should be made only after consideration and further discussion with your physician. For more information, please contact Orthopedic Spine and Sports Medicine Center at 201-587-1111.